The COVID-19 pandemic presented unprecedented challenges to patients, family members, and healthcare staff that resulted in increased stress and isolation and decreased quality of life. We evaluate ...the impact of a novel virtual concert program, the Vital Sounds Initiative (VSI) of Project: Music Heals Us (PMHU), which began at the beginning of the pandemic to combat patient isolation and provide employment to professional musicians. Using a qualitative analysis of VSI data, we examined post-concert written responses by musicians. These responses were coded by independent coders via inductive coding and thematic analysis. Between 7 April 2020 and 20 July 2022, 192 musicians played 2203 h of music for 11,222 audience members in 39 care facilities nationwide. A total of 114 musicians submitted a total of 658 responses. Three main themes (with corresponding subthemes) arose: (1) Patient Experience; (2) Musician Experience; (3) Caregiver (family or staff) Experience. The responses offered valuable insight into the overwhelmingly positive aspects of the virtual concerts. Overall, we found that VSI favorably impacts individuals at every level, including the patients, musician, and caregivers. These findings provide preliminary evidence for the benefits of virtual music concerts. Upscaling similar virtual music interventions/programs should be considered.
The aim of this study was to evaluate recent trends and the adoption of practice recommendations for menopausal hormone therapy (MHT) use from 2001 to 2009 by formulation, dose, woman's age, and ...characteristics of physicians reporting MHT visits.
The IMS Health (Plymouth Meeting PA) National Disease and Therapeutic Index physician survey data from 2001 to 2009 were analyzed for visits in which MHT use was reported by US office-based physicians. Estimated national volume of visits for which MHT use was reported.
MHT use declined each year since 2002. Systemic MHT use fell from 16.3 million (M) visits in 2001 to 6.1 M visits in 2009. Declines were greatest for women 60 years or older (64%) but were also substantial for women younger than 50 years (59%) and women 50 to 59 years old (60%). Women 60 years or older accounted for 37% of MHT use. Lower dose product use increased modestly, from 0.7 M (2001) to 1.3 M (2009), as did vaginal MHT use, from 1.8 M (2001) to 2.4 M (2009). Declines in continuing systemic MHT use (65%) were greater than for newly initiated MHT use (51%). Compared with other physicians, obstetrician/gynecologists changed their practices less, thereby increasing their overall share of total MHT visits from 72% (2001) to 82% (2009).
Total MHT use has steadily declined. Increased use of lower dose and vaginal products reflects clinical recommendations. Uptake of these products, however, has been modest, and substantial use of MHT continues in older women.
To evaluate recent trends, we examined longitudinal national data on the outpatient use of warfarin in atrial fibrillation (AF), beta-blockers and aspirin in coronary artery disease (CAD), and ...angiotensin-converting enzyme inhibitors (ACEIs) in congestive heart failure (CHF).
Previous studies indicate that specific cardiac medications are underutilized.
We used the National Disease and Therapeutic Index (NDTI) (produced by IMS HEALTH, Plymouth Meeting, Pennsylvania) for 1990 to 2002, and the National Ambulatory Medical Care Surveys (NAMCS) for 1990 to 2000 to follow nationally representative samples of outpatient visits. For visits by patients with AF (total n = 14,634 visits), CAD (n = 35,295), and CHF (n = 33,008), we examined trends in the proportion of visits with the selected medications reported.
Warfarin use in AF increased from 12% in 1990, to 41% in 1995, to 58% in 2001 in NDTI; a similar moderation of recent increase was seen in NAMCS. For CAD in NDTI, beta-blocker use increased slowly from 19% in 1990, to 20% in 1995, then to 40% in 2001; NAMCS showed this same pattern. Aspirin use in CAD in NDTI increased from 18% in 1990, to 19% in 1995, to 38% in 2001; NAMCS, however, showed lower use rates. For NDTI, ACEI use in CHF increased from 24% in 1990 to 36% in 1996, but increased to only 39% by 2001, a general pattern also seen in NAMCS.
Both national datasets demonstrate continuing underutilization of these cardiac medications of proven benefit. Although use is increasing, it remains lower than expected, and some increases noted in earlier years have slowed. Substantial public health benefits would result from further adoption of these effective therapies.
Abstract
Objective. This study aims to determine 1) the epidemiology of perioperative opioid use; and 2) the association between patterns of preoperative opioid use and time-to-cessation of ...postoperative opioids.
Design. Retrospective, cohort study.
Setting. National, population-level study of Veterans Healthcare Administration (VHA) electronic clinical data.
Subjects. All VHA patients (n = 64,391) who underwent surgery in 2011, discharged after stays of ≥1 day, and receiving ≥1 opioid prescription within 90 days of discharge.
Methods. Patients’ preoperative opioid use were categorized as 1) no opioids, 2) tramadol only, 3) short-acting (SA) acute/intermittent (≤ 90 days fill), 4) SA chronic (> 90 days fill), or 5) any long-acting (LA). After defining cessation as 90 consecutive, opioid-free days, the authors calculated time-to-opioid-cessation (in days), from day 1 to day 365, after hospital discharge. The authors developed extended Cox regression models with a priori identified predictors. Sensitivity analyses used alternative cessation definitions (30 or 180 consecutive days).
Results. Almost 60% of the patients received preoperative opioids: tramadol (7.5%), SA acute/intermittent (24.1%), SA chronic (17.5%), and LA (5.2%). For patients opioid-free preoperatively, median time-to-cessation of opioids postoperatively was 15 days. The SA acute/intermittent cohort (HR =1.96; 95% CI =1.92-2.00) had greater risk for prolonged time-to-cessation than those opioid-free (reference), but lower risk than those taking tramadol only, SA chronic (HR = 9.09; 95% CI = 8.33-9.09), or LA opioids (HR = 9.09; 95% CI = 8.33-10.00). Diagnoses of chronic pain, substance-use, or affective disorders were weaker positive predictors. Sensitivity analyses maintained findings.
Conclusion. Greater preoperative levels of opioid use were associated with progressively longer time-to-cessation postoperatively.
About 1 in 3 adults aged 65 and older falls annually. Exercise interventions are effective in reducing the fall risk and fall rate among older adults. In 2020, startup company Age Bold Inc. ...disseminated the Bold Fall Prevention Program, aiming to reduce falls among older adults through a remotely delivered, digital exercise program.
We conducted a feasibility study to assess the delivery of the Bold Fall Prevention Program remotely and evaluate the program's impact on 2 primary outcomes-annualized fall rate and weekly minutes of physical activity (PA)-over 6 months of follow-up.
Older adults at high risk of falling were screened and recruited for the feasibility study via nationwide digital advertising strategies. Self-reported outcomes were collected via surveys administered at the time of enrollment and after 3 and 6 months. Responses were used to calculate changes in the annualized fall rate and minutes of PA per week.
The remote delivery of a progressive digital fall prevention program and associated research study, including remote recruitment, enrollment, and data collection, was deemed feasible. Participants successfully engaged at home with on-demand video exercise classes, self-assessments, and online surveys. We enrolled 65 participants, of whom 48 (74%) were women, and the average participant age was 72.6 years. Of the 65 participants, 54 (83%) took at least 1 exercise class, 40 (62%) responded to at least 1 follow-up survey at either 3 or 6 months, 20 (31%) responded to both follow-up surveys, and 25 (39%) were lost to follow-up. Among all participants who completed at least 1 follow-up survey, weekly minutes of PA increased by 182% (ratio change=2.82, 95% CI 1.26-6.37, n=35) from baseline and annualized falls per year decreased by 46% (incidence rate ratio IRR=0.54, 95% CI 0.32-0.90, n=40). Among only 6-month survey responders (n=31, 48%), weekly minutes of PA increased by 206% (ratio change=3.06, 95% CI 1.43-6.55) from baseline to 6 months (n=30, 46%) and the annualized fall rate decreased by 28% (IRR=0.72, 95% CI 0.42-1.23) from baseline to 6 months.
The Bold Fall Prevention Program provides a feasible strategy to increase PA and reduce the burden of falls among older adults.
IMPORTANCE Describing the relationship between the availability of free prescription drug samples and dermatologists’ prescribing patterns on a national scale can help inform policy guidelines on the ...use of free samples in a physician’s office. OBJECTIVES To investigate the relationships between free drug samples and dermatologists’ local and national prescribing patterns and between the availability of free drug samples and prescription costs. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study investigating prescribing practices for acne, a common dermatologic condition for which free samples are often available. The settings were, first, the offices of nationally representative dermatologists from the National Disease and Therapeutic Index (an IMS Health Incorporated database) and, second, an academic medical center clinic without samples. Participants were ambulatory patients who received a prescription from a dermatologist for a primary initial diagnosis of acne vulgaris or rosacea in 2010. MAIN OUTCOMES AND MEASURES National trends in dermatologist prescribing patterns, the degree of correlation between the availability of free samples and the prescribing of brand-name medications, and the mean cost of acne medications prescribed per office visit nationally and at an academic medical center without samples. RESULTS On a national level, the provision of samples with a prescription by dermatologists has been increasing over time, and this increase is correlated (r = 0.92) with the use of the branded generic drugs promoted by these samples. Branded and branded generic drugs comprised most of the prescriptions written nationally (79%), while they represented only 17% at an academic medical center clinic without samples. Because of the increased use of branded and branded generic drugs, the national mean total retail cost of prescriptions at an office visit for acne was conservatively estimated to be 2 times higher (approximately $465 nationally vs $200 at an academic medical center without samples). CONCLUSIONS AND RELEVANCE Free drug samples can alter the prescribing habits of physicians away from the use of less expensive generic medications. The benefits of free samples in dermatology must be weighed against potential negative effects on prescribing behavior and prescription costs.
Essential hypertension is the most common diagnosis in US primary care settings for middle-aged persons and seniors. Yet, data on hypertension screening, treatment, and control in such settings are ...limited. We analyzed National Ambulatory Medical Care Survey data to examine the rates of and factors associated with hypertension screening, treatment, and control during US office visits in 2003 and 2004. Blood pressure was measured in 56% (95% confidence limits52% to 59%) of all visits by patients ≥18 years of age and in 93% (95% confidence limits89% to 96%) of hypertensive patient visits. Among the latter, 62% (95% confidence limits55% to 69%) were treated. Diuretics were the most commonly prescribed antihypertensive agents (46%; 95% confidence limits41% to 50%), and combination therapy was reported in 58% (95% confidence limits54% to 63%) of treated visits. Only 39% (95% confidence limits34% to 43%) of treated visits were at recommended blood pressure goals. The odds of not being screened for hypertension were notably greater for visits with a provider other than a primary care physician or cardiologist (10.0; 95% confidence limits5.5 to 16.7) and for nonwell care visits (5.6; 95% confidence limits3.6 to 8.3). Greater odds of not being treated for hypertension were noted by geographic region (South versus Northeast2.6; 95% confidence limits1.2 to 5.6) and visit type (first time versus return visits; 1.6; 95% confidence limits1.1 to 2.4). The odds of not having blood pressure controlled were greater for patients with comorbidities (1.6; 95% confidence limits1.1 to 2.4). In conclusion, more intervention efforts are needed to further reduce the gaps and variations in routine practice in relation to evidence-based practice guidelines for hypertension screening, treatment, and control.
CONTEXT
Postmenopausal hormone therapy increases the risk of venous thrombosis.
It is not known whether other factors influencing thrombosis add to this risk.
OBJECTIVE
To report final data on ...incidence of venous thrombosis in the Women’s
Health Initiative Estrogen Plus Progestin clinical trial and the association
of hormone therapy with venous thrombosis in the setting of other thrombosis
risk factors.
DESIGN, SETTING, AND PARTICIPANTS
Double-blind randomized controlled trial of 16 608 postmenopausal
women between the ages of 50 and 79 years, who were enrolled in 1993 through
1998 at 40 US clinical centers with 5.6 years of follow up; and a nested case-control
study. Baseline gene variants related to thrombosis risk were measured in
the first 147 women who developed thrombosis and in 513 controls.
INTERVENTION
Random assignment to 0.625 mg/d of conjugated equine estrogen plus 2.5
mg/d of medroxyprogesterone acetate, or placebo.
MAIN OUTCOME MEASURES Centrally validated deep vein thrombosis and pulmonary embolus. RESULTS
Venous thrombosis occurred in 167 women taking estrogen plus progestin
(3.5 per 1000 person-years) and in 76 taking placebo (1.7 per 1000 person-years);
hazard ratio (HR), 2.06 (95% confidence interval CI, 1.57-2.70). Compared
with women between the ages of 50 and 59 years who were taking placebo, the
risk associated with hormone therapy was higher with age: HR of 4.28 (95%
CI, 2.38-7.72) for women aged 60 to 69 years and 7.46 (95% CI, 4.32-14.38)
for women aged 70 to 79 years. Compared with women who were of normal weight
and taking placebo, the risk associated with taking estrogen plus progestin
was increased among overweight and obese women: HR of 3.80 (95% CI, 2.08-6.94)
and 5.61 (95% CI, 3.12-10.11), respectively. Factor V Leiden enhanced the
hormone-associated risk of thrombosis with a 6.69-fold increased risk compared
with women in the placebo group without the mutation (95% CI, 3.09-14.49).
Other genetic variants (prothrombin 20210A, methylenetetrahydrofolate reductase
C677T, factor XIII Val34Leu, PAI-1 4G/5G, and factor V HR2) did not modify
the association of hormone therapy with venous thrombosis.
CONCLUSIONS
Estrogen plus progestin was associated with doubling the risk of venous
thrombosis. Estrogen plus progestin therapy increased the risks associated
with age, overweight or obesity, and factor V Leiden.
BACKGROUND: Timely heart failure (HF) diagnosis can lead to earlier intervention and reduced morbidity. Among historically marginalized patients, new-onset HF diagnosis is more likely to occur in ...acute care settings (emergency department or inpatient hospitalization) than outpatient settings. Whether inequity within outpatient clinician practices affects diagnosis settings is unknown. METHODS: We determined the setting of incident HF diagnosis among Medicare fee-for-service beneficiaries between 2013 and 2017. We identified sociodemographic and medical characteristics associated with HF diagnosis in the acute care setting. Within each outpatient clinician practice, we compared acute care diagnosis rates across sociodemographic characteristics: female versus male sex, non-Hispanic White versus other racial and ethnic groups, and dual Medicare-Medicaid eligible (a surrogate for low income) versus nondual-eligible patients. Based on within-practice differences in acute diagnosis rates, we stratified clinician practices by equity (high, intermediate, and low) and compared clinician practice characteristics. RESULTS: Among 315 439 Medicare patients with incident HF, 173 121 (54.9%) were first diagnosed in acute care settings. Higher adjusted acute care diagnosis rates were associated with female sex (6.4% 95% CI, 6.1%–6.8%), American Indian (3.6% 95% CI, 1.1%–6.1%) race, and dual eligibility (4.1% 95% CI, 3.7%–4.5%). These differences persisted within clinician practices. With clinician practice adjustment, dual-eligible patients had a 4.9% (95% CI, 4.5%–5.4%) greater acute care diagnosis rate than nondual-eligible patients. Clinician practices with greater equity across dual eligibility also had greater equity across sex and race and ethnicity and were more likely to be composed of predominantly primary care clinicians. CONCLUSIONS: Differences in HF diagnosis rates in the acute care setting between and within clinician practices highlight an opportunity to improve equity in diagnosing historically marginalized patients.
PDF
